The only difference between ICD-10-PCS root operations Excision and Resection is the amount of the body part removed. Jennifer Avery, CCS, COC, CPC, CPC-I, Anita Rapier, RHIT, CCS, and Cheree Lueck, BSN, RN, provide tips for determining the correct root operation.
Every once in a while, another facility will send us a case to review and help them code. Here at the Fix ‘Em Up Clinic, we are happy to share our knowledge as we prepare for October 1. In that...
The expanded code set available in ICD-10-CM will give providers the chance to better tell the story of each patient’s care. Glenn Krauss , RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM, explains how coders can assist physicians in telling that story .
Q: I have a question regarding facility coding for evaluation and management (E/M) levels, not for an ED physician, but for facility-level nursing in the ED. If a specialist is called to evaluate or consult on a patient, the nursing intervention is what the facility-level criteria is based on. For example, a patient has difficulty walking, a nurse assists the patient to get an x-ray, takes vitals, does an initial assessment, then provides discharge instructions of moderate complexity. I would code this scenario as a level 3.
ICD-10 implementation is almost here, but coders are still facing resistance from physicians. W. Jeff Terry, MD, highlights ICD-10 challenges from the physician perspective, while Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, responds from a coder’s point of view.
The 2016 OPPS proposed rule introduces APC restructuring, new comprehensive APCs, and many other potential changes for next year. Jugna Shah, MPH, and Debbie Mackaman, RHIA, CPCO, CCDS, review the proposals and what they could mean for providers.
CMS is proposing a new status indicator to be assigned to laboratory tests so when the tests are the only service on a claim, CMS will pay for them separately under the Clinical Laboratory Fee Schedule without providers having to do anything additional from a reporting perspective.
We’re 43 (calendar) days from ICD-10 implementation. We’ve only got 31 working days until October 1. If you are all set for ICD-10, you’re probably fine tuning your coding and documentation, maybe...
Kids will soon be heading back to school here in Anytown, which also means the sports teams are holding preseason camps. And some of our local players practice a little too hard. Take Shaun, for...
Medical record audits provide opportunities to educate coders, physicians, and/or clinical documentation improvement specialists. Robert S. Gold, MD, offers tidbits about volume overload and heart failure from recent reviews he’s done.
Drainage procedures can be therapeutic in nature or diagnostic, such as when a physician removes a fluid or gas for biopsy. A nita Rapier, RHIT, CCS, Nelly Leon-Chisen, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , highlight the differences in coding diagnostic and therapeutic thoracocentesis and lumbar tap procedures in ICD-10-PCS.
Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?
With Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. Cathie Wilde, RHIA, CCS, and Kim Carr, RHIT, CCS, CDIP, CCDS, explain why organizations still need to be able to justify code assignment.
The absolute best ICD-10 education is completely free, assuming you have an Internet connection. It will tell you everything you need to know about coding in ICD-10. What is this magical, mystical...
Armadillos apparently pose more hazards to your health than just passing on leprosy. A Texas man recently tried to shoot an armadillo three times and ended up being hit by his own bullet . He claims...
Hospitals did not get any ICD-10 relief as part of CMS’ accord with the AMA regarding a specificity grace period . However, they might not need much help, according to the latest Workgroup for...
CMS has repeatedly tweaked its logic regarding comprehensive APCs since inception. Dave Fee, MBA, reviews the latest changes regarding complexity adjustments, as well as new and deleted codes.
Q: We had a patient come into our ED with a severe head injury. To protect his airway, we intubated the patient. Can we report an emergency endotracheal intubation (CPT ® code 31500) and CPR (92950) together if only bagging happens and no chest compressions?
